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Thursday, September 25th, 2008
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Making the Cut: How Cosmetic Surgery Is Transforming Our Lives

by Anthony Elliot

Skin Deep

A review by Sherwin B. Nuland

Lying on a couch in the office of one of the hairdressing salons that she owns in London, Sharyn Hughes perused the advertising brochure she had been sent by Makeover Getaways:

"Our Malaysian Makeover Package is a brilliant combination of surgery treatments, sunny beaches and shopping. Offering the latest technological facilities in an exceptionally clean hospital environment, and with guaranteed five star hotel accommodation for postoperative recovery and holiday, you will return home fully revitalized and looking wonderful."

Within minutes, she decided that this opportunity for what she called a "thorough overhaul" was precisely what she and her partner, Grant, had been seeking. They would join the 100,000 other men and women who became surgical tourists to Malaysia in 2006, up from 40,000 only three years earlier. For Sharyn's breast enlargement, liposuction, and cosmetic dentistry and Grant's liposuction and cosmetic dentistry, the total cost would be £9,000 (considerably less than the same surgery in London), with a tour of the country included. She phoned Grant about her discovery, and began making arrangements for both of them to fly off to Asia for their rejuvenation.

In his thought-provoking and disturbing new book, Anthony Elliott describes Asia as having become "the world's hotspot for surgical tourism, particularly Thailand, Singapore and India." Hungary, Latvia, Lithuania, Latin America, the Caribbean states, and parts of the Middle East have witnessed a similar phenomenon, as cosmetic surgery has become as globalized as any other industry -- not only for patients, but also for the professional personnel who provide it. The demand for such services and the mobility of the providers has magnified in recent years, and by every indication it will continue to do so for the foreseeable future. Indeed, the entire concept of periodically re-imagining oneself - -more, re-designing oneself -- has taken its place in the culture of Western societies.

Elliott is a professor of sociology, and he has trained his keen sociologist's eye on the astonishing phenomenon that cosmetic surgery has become. Using the methods of his field of study, he now presents us with this small and insightful book that is sure to alter the perspective of everyone who reads it. It is Elliott's contention that there are three cultural forces, acting together and separately, that create the conditions driving the urge for the periodic reinvention of the self. It is an urge that has gripped many members of our society and will affect increasing numbers of those influenced by Elliott's three forces -- numbers that include just about everyone. Those forces are the cult of celebrity, consumerism, and the new economy characterized by globalization.

The influence of celebrity culture, Elliott points out, has exploded in the first years of the twenty-first century. In a volcanic process abetted by new technologies such as DVDs and satellite television, the private lives of show-business personalities and other rich and famous people have become available at any given moment for the scrutiny of anyone who cares to look. Documented by continuous global media of various sorts, the body parts of celebrities are closely watched as they are exchanged for the latest variation in physical form. Celebrities not only transform themselves in the glare of the limelight, but many of them are willing -- enthusiastic, in fact -- to describe the details of their various transformations to reporters, TV commentators, and fans. Such well-known figures as Cher, Pamela Anderson, and Demi Moore proudly, even defiantly embrace a culture of inauthenticity.

It is no wonder that their millions of admirers do not hesitate to think of cosmetic surgery as the norm, and the periodically re-created body as one to admire. Cosmetic surgeons relate the tales of patients who arrive in their private clinics with urgent requests such as "I want lips and cheekbones like Angelina's." And not only female celebrities are on the list of cosmetic exempla. Mickey Rourke, Robert Redford, and Sylvester Stallone are also among those about whom the gossip mill has plenty to divulge. The "unprecedented levels of interest in the lives, loves, and scandals of celebrities, and particularly fascination with their secrets and surgeries, have been widely viewed as a central driving force of cosmetic surgical culture," Elliott tells us.

Many people now reject the notion that one should look older as one biologically ages. Inspired by the public example of the stars, ordinary men and women beat a path to the plastic surgeon's office in search of a youth that can be renewed at any stage of life. In a consumer society, a makeover of one's appearance is just another product to be bought when it is desired, and is not infrequently accompanied by a makeover of the self, to conform with the new image. Expectations run high, and, not unsurprisingly, they include the admiration of the opposite sex.

No longer is vanity or narcissism the major stimulus to cosmetic improvement. It is unlikely that Sharyn realized it, but in signing up for her Malaysian makeover she was acting in accordance with the principles of the consumer culture in which we now live. In this atmosphere, cosmetic surgery is a product to be sold by its vendors, and the current generation of purchasers treat it as something for which they shop, like a new refrigerator or cell phone. And like other products, their desire for it is influenced by two strategies employed by the consumer industry in such a way that the buyer always wants more. The first is to devalue the product soon after it has been bought, as when a more advanced form of mobile phone hits the market and makes the previous model obsolete. The second is to satisfy the consumer's desires in such a way that new desires are created.

The case of Sharyn is a perfect example of this pattern. Long a consumer of Botox injections and various forms of beauty creams, she came to believe that her ideal self could not be realized unless she took the more invasive measure of undergoing surgery. Elliott undertook a study of women's magazines and was struck by the hypnotic power of the advertisements for various surgical procedures. Women exposed to them can hardly be blamed if they come to believe that the standard of beauty is determined by the appearance of the body that has been altered by the scalpel. The subliminal message transmitted by the beauty industry is that people can re-invent themselves whenever they choose. Since surgical enhancements are not contrived to last, they fulfill the requirements for which they were designed.

"Increasingly, cosmetic surgeons dispatch their patients home with a brochure, catalogue or DVD -- in which is outlined other cosmetic procedures by which one can keep one's surgically enhanced body up to scratch. In marketing terms, this involves deflecting attention from the particular procedure undergone and broadening the advertising coverage to encompass the barrage of procedures now offered by cosmetic surgical culture. In this way, the market for cosmetic surgery is maintained through selling its associations, linkages and possibilities."

Financial inducements are sometimes offered: a guaranteed price for signing up right now; a discount for bringing in a coupon clipped from a magazine; alter one body area and get one free. These concepts are all derived from the world of marketing, not medicine.

The third force that has contributed to the boom in cosmetic surgery is economic. Originally with the thought of obtaining a career edge, more than a few executive types have sought physical re-invention merely to keep up. "Globalization is a world of transformations," Elliott remarks, in which perpetual change -- the continual renewal of self-actualization--is the key to success. Much of this is due to a workplace ambience in which career changes are far more common than they have been in the past, often requiring the acquisition of an entirely new set of skills. We have already reached the point where the average American graduating from college can expect to hold twelve different jobs in a lifetime and change his or her skill base at least three times. In such an atmosphere, job security becomes a thing of the past, as does employee loyalty. Everyone is a short-termer, increasingly concerned that his job will disappear or he will be displaced by a younger, more vibrant-appearing person.

This is a price we pay for the speed of intensive globalization. There is a dynamism to it that over-runs us, and in which we will be drowned if we do not take measures to keep current. Increasingly, such measures include the physical and emotional makeover. By these means, the culture of cosmetic surgery becomes an integral component of globalization. "In a world of short-term contracts, endless downsizings, just-in-time deliveries and multiple careers," Elliott observes, "the capacity to change and reinvent oneself has become fundamental."

Driven by the relentless energy of all these forces, then, cosmetic overhaul has become an indispensable aspect of the lifestyles of a substantial portion of certain elements of Western society. Celebrities are its vanguard; consumerism is its modus operandi; and globalism creates an economic urgency that makes its progress irresistible. All evidence points toward an ongoing increase in the influence of all three.

None of this could have occurred, of course, without the enthusiastic participation of the surgeons who deliver the product. Though Elliott does not discuss this aspect of his subject, it is difficult for anyone even remotely placed within the ranks of the medical profession to read his chapters without wincing -- unless, of course, they are among the providers. At the very least, the surgery described in this book represents a misuse of resources. While they probably cannot, strictly speaking, be called unethical in the usual sense, these procedures and operations--and the hucksterism associated with them -- seem rarely to qualify as unalloyed examples of the healer's art. Certainly, they were not what was intended by the pioneers of plastic surgery and their principled followers.

As for the medical ethicists, I must note that their literature is singularly free of commentary on cosmetic surgery or any of the uses to which it has been put. The literature of surgery itself contains many articles on the techniques being employed, but it has nothing to say about the context or the milieu in which they are offered to the public. The only textbook devoted completely to the ethics of surgery -- Surgical Ethics, to which thirty-nine surgeons and ethicists contributed -- is now ten years old, and there is no mention of the problem in any of its nineteen chapters. Neither does the four-page Code of Ethics of the American Board of Plastic Surgery, which is the governing body for the specialty, address the issue.

I do not wish to be misunderstood. I am not saying that performing these operations is in itself unethical, merely that the reasons for this intervention in the body are cultural, not medical; and that the associated hustling has a low and unpleasant odor about it, which could do with more attention from the respective communities of surgeons and ethicists than it has yet received. Anything connected with the healer's art should be as far above suspicion as Caesar's wife.

Worst of all for its customers, the instability of that imperative of "making the cut" intrudes itself into daily life, seeping into self-image, and habits, and even identity, and makes all of these once-steadfast qualities now seem disposable. All of this brings with it a kind of fear and a sense of loss of what is real, not only on the part of those who go chasing after reinvention but also for everyone with whom they interact. Anthony Elliott ends his book with a warning that, in a single sentence, epitomizes its wise and disheartening message: "The wider social costs mean that we are all debased by this soulless surgical culture."

Sherwin B. Nuland is a frequent contributor to The New Republic.


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